CORNERSTONECHRISTIANCHURCHDISCLOSURESTATEMENTAPPLICATIONFORVOLUNTEERS

RequiredbytheChildProtectiveServiceLaw23Pa.C.S.Section6344.2(relatingtovolunteershavingcontactwithchildren)

I swear/affirm that I am seeking a volunteer position and AM NOT required toobtainaclearancethroughtheFederalBureauofInvestigation,as:

• ThepositionIamapplyingforisunpaid;and• IhavebeenaresidentofPennsylvaniaduringtheentiretyofthepreviousten

yearperiod.Iswear/affirmthatIhaveneverbeennamedasaperpetratorofafoundedreportofchildabuseasdefinedbytheChildProtectiveServicesLaw.Iswear/affirmthatIhavenotbeenconvictedofanyofthefollowingcrimesunderTitle18ofthePennsylvaniaconsolidatedstatuesorofoffensessimilarinnaturetothose crimes under the laws or former laws of the United States or one of itsterritories or possessions, another state, the District of Columbia, theCommonwealth of Puerto Rico or a foreign nation, or under a former law of thisCommonwealth.

• Chapter25 relatingtocriminalhomicide• Section2702 relatingtoaggravatedassault• Section2709 relatingtostalking• Section2901 relatedtokidnapping• Section2902 relatingtounlawfulrestraint• Section3121 relatingtorape• Section3122.1 relatingtostatutorysexualassault• Section3123 relatingtoinvoluntarydeviatesexualintercourse• Section3124.1 relatingtosexualassault• Section3125 relatingtoaggravatedindecentassault• Section3126 relatingtoindecentassault• Section3127 relatingtoindecentexposure• Section4302 relatingtoincest• Section4303 relatingtoconcealingdeathofchild• Section4304 relatingtoendangeringwelfareofchildren• Section4305 relatingtodealingininfantchildren• Section5902(b) relatingtoprostitutionandrelatedoffenses• Section5903(c)(d) relatingtoobsceneandothersexualmaterialand

performances• Section6301 relatingtocorruptionofminors• Section6312 relatingtosexualabuseofchildren,oranequivalent

crimeunderFederallaworthelawofanotherstate• The attempt, solicitation, or conspiracy to commit any of the offenses set

forthinthislist.

• AfelonyoffenseundertheactofApril14,1972(P.L.233,No.64)knownasTheControlledSubstance,Drug,DeviceandCosmeticAct,committedwithinthefiveyearperiodimmediatelyprecedingverificationunderthissection.

IunderstandthatIshallnotbeapprovedforserviceifIamnamedasaperpetratorofafoundedreportofchildabuseorhavebeenconvictedofanyofthecrimeslistedaboveorofoffensessimilarinnaturetothosecrimesunderthelawsorformerlawsoftheUnitedStatesoroneofitsterritoriesorpossessions,anotherstate,theDistrictof Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under aformerlawofthisCommonwealth.I understand that if I am arrested for or convicted of an offense that wouldconstitutegroundsfordenyingparticipationinaprogram,activityorserviceundertheChildProtectiveServicesLawaslistedabove,oramnamedasperpetratorinafounded or indicated report, I must provide Cornerstone Christian Church withwrittennoticenotlaterthan72hoursafterthearrest,convictionornotificationthatIhavebeenlistedasaperpetratorintheStatewidedatabase.IunderstandthatifCornerstoneChristianChurchhasareasonablebeliefthatIwasarrested or convicted for an offense that would constitute grounds for denyingparticipation in a program, activity or service under the Child Protective ServicesLaw, or was named as a perpetrator in a founded or indicated report, of I haveprovidednoticeasrequiredunderthissection,CornerstoneChristianChurchshallimmediately require me to submit current clearances obtained through theDepartment of Human Services, The Pennsylvania State Police, and the FederalBureauofInvestigation,asappropriate.IunderstandthatifIwillfullyfailtodiscloseinformationrequiredabove,Icommitamisdemeanor of the third degree and shall be subject to discipline up to andincludingdenialofavolunteerposition.I understand that he person responsible for employment decisions or theadministratorofaprogram,activityorserviceisrequiredtomaintainacopyofmyclearances.Iherebyswear/affirmthatallstatementsinthewithinAffidavitaretrueandcorrectto the best of my knowledge, information and belief. I understand that falsestatements in this Affidavit will be subject to my immediate termination of myservicestoCornerstoneChristianChurch.Ifurtherunderstandthatmystatementsare subject to the penalties of 18 PA C.S. Section 4904 relating to unswornfalsificationtoauthorities,whichprovidethatifIknowinglymakefalsestatements,canandwillbesubjectmetocriminalpenalties.Name:_______________________________________ Signature:___________________________________Witness:____________________________________ Signature:___________________________________Date:________________________________________